A 37-year-old woman presented to the emergency department (ED) with 12 hours of fever and lower abdominal cramp pain. She had a history significant for hypothyroidism, infertility, and dysmenorrhea and had a hysterosalpingography (HSG) 48 hours prior for a comprehensive infertility workup.
On examination, the patient’s vital signs were a 94 bpm heart rate; 109/64 mm Hg blood pressure; 14 breaths per minute respiratory rate; 99% oxygen saturation on room air; and 101.2 °F temperature. The patient reported pain in the bilateral lower abdominal quadrants and no history of sexually transmitted infection, pelvic inflammatory disease, vaginal discharge or bleeding, dysuria, hematuria, melena, or bright red blood per rectum. A human chorionic gonadotropin urine test was negative on intake. The HSG 48 hours prior showed no concerning findings with normal uterine cavity and normal caliber fallopian tubes bilaterally.
On physical examination, the patient’s abdomen was nondistended, nonperitonitic, and without evidence of acute trauma or surgical scars. On palpation, the patient was tender in her suprapubic region and lower abdominal quadrants without evidence of guarding or rebound tenderness. At rest, the patient rated her abdominal pain 4 out of 10 and 7 out of 10 upon palpation. On pelvic examination, there was normal appearing external genitalia without evidence of discharge or bleeding. Her vaginal vault was atraumatic with a minimal amount of physiologic discharge. Her cervix was normal in appearance without evidence of cervicitis. We obtained swabs for Neisseria gonorrhoeae (N gonorrhoeae) and Chlamydia trachomatis (C trachomatis), which were negative. On bimanual pelvic examination, the patient had no cervical motion tenderness, and no adnexal masses were palpable. However, on palpation of the adnexa, she endorsed a localized dull, nonradiating 6 out of 10 right-sided pain/tenderness.
The patient’s initial laboratory tests were as follows: white blood cells, 20.1 × 103/μL (reference range, 4-11 × 103/μL); hemoglobin, 12.1 g/dL (reference range, 12.1-15.1 g/dL); hematocrit, 37.1%, (reference range, 36%-48%); alanine aminotransferase, 84 U/L (reference range, 7-56 U/L); aspartate aminotransferase, 66 U/L (reference range, 8-33 U/L); and lipase, 25 U/L (5-60 U/L). Urinalysis was notable for only 5 red blood cells and negative for white blood cells, leukocyte esterase, and nitrites. The patient’s pain and fever were controlled with 1 g IV acetaminophen.
The patient’s fever, leukocytosis, and physical examination were concerning for possible intra-abdominal processes, so a computed tomography (CT) of her abdomen and pelvis with IV contrast was obtained for further evaluation. The CT showed bilateral tubular rim-enhancing fluid collections within bilateral adnexa with the right fluid collection measuring 3.7 × 3.5 × 4.0 cm and the left 4.8 × 3.5 × 3.2 cm with associated fat stranding and trace-free fluid in the abdomen (Figure).
Discussion
The patient was diagnosed with bilateral tubo-ovarian abscess (TOA) likely secondary to her HSG procedure 48 hours before. TOA is a severe infectious, inflammatory condition involving a mass of the ovaries, fallopian tubes, or adjacent tissues of the upper female genital tract.1 Traditionally, TOAs are sequelae of undiagnosed or subclinical acute or chronic pelvic inflammatory disease (PID). This is known to occur via pathogen ascension from the lower to the upper female genital tract resulting in cervicitis, endometritis, salpingitis, oophoritis, and if left untreated, peritonitis.1 About 70,000 women are diagnosed with TOAs in the US every year. These patients require hospitalization as well as IV antibiotics for gold-standard treatment; however, some cases may require percutaneous drainage based on size, severity, and location.2